If the applicant/beneficiary or authorized representative does not sign the patient acknowledgement, indicate the reason.
Illnesses and injuries: describe all significant physical and mental illnesses, accidents, deformities, injuries and surgeries related to the patient's disability.
Dates and reports: specify date(s) applicable to the condition(s) listed and attach copies of all related reports.
Diagnoses: list the current diagnoses, primary diagnosis first.
Medical evidence: attach copies of all medical evidence to this report.
| Question | Answer |
|---|---|
| Form Name | Form DHS 1128 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 50 |
| Avg. time to fill out | 9 min |
| Other names | DHS1128, DHS-1128, Form DHS 1128, Hawaii Med-QUEST disability report, Med-QUEST Disability Report |
| Edition | Rev 10/2022 |
| Issuing agency | State of Hawaii Med-QUEST Division, Department of Human Services |
| Official source | Form DHS 1128 (Rev 10/2022), State of Hawaii Med-QUEST Division, Department of Human Services |
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